Massive Medicaid gap could gut health care law

Many poor may miss coverage

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WASHINGTON — Nearly 2 in 3 uninsured low-income people who would qualify for subsidized coverage under President Obama’s health care law may be out of luck next year because their states have not expanded Medicaid.

An Associated Press analysis of figures from the Urban Institute finds a big coverage gap developing, with 9.7 million out of 15 million potentially eligible adults living in states that are refusing the expansion or are undecided with time running short.

That a majority of the neediest people who could be helped by the law may instead remain uninsured is a predicament unforeseen by Obama and congressional Democrats who designed a sweeping extension of the social safety net. The law’s historic promise of health insurance for nearly all US residents would not be fulfilled as envisioned.

It’s the direct consequence of last summer’s Supreme Court decision that gave states the right to opt out of the Medicaid expansion, combined with unyielding resistance to the law from many Republican state lawmakers.

Expanding Medicaid is essential to Obama’s two-part strategy for covering the uninsured.

Starting next year, middle-class people without job-based coverage will be able to get tax credits to help them buy private insurance. But the law calls for low-income people to enroll in Medicaid, expanded to accommodate a largely excluded group: adults with no children at home. Expanded Medicaid would cover about half the 25 million to 30 million people who could be helped by the law.

Twenty-three states and the District of Columbia have decided to accept the expansion, which is fully financed by Washington for the first three years and phases down gradually to a 90 percent federal share. Among those are six states led by Republican governors.

But the majority of low-income Americans newly eligible for Medicaid under the law live in states such as Texas, Florida, and Georgia, where political opposition remains formidable.

‘‘Because of the Supreme Court’s decision making Medicaid expansion optional with the states, we’re going to see some pretty significant differences in this country from one place to another in terms of access to health care and access to health insurance,’’ said Gary Cohen, the Health and Human Services official overseeing the rollout of the law.

Speaking this past week at the Brookings Institution, Cohen added: ‘‘We are going to have an opportunity . . . to take a look at that in a year and see what difference it made, the choices that were made at the political level to do one thing rather than another.

‘‘And that’s going to be a pretty profound difference and a pretty profound choice that we get to make every couple of years about what kind of country we want to be,’’ Cohen continued.

Elections for state offices and Congress will be held next year. Republican state lawmakers continue to oppose the expansion for several reasons. Many believe Medicaid has too many problems already. Others worry that Washington will renege on financing, and some believe health care is an individual responsibility, not a government obligation.

GOP health policy expert Gail Wilensky said she did not expect so many states to turn down the Medicaid expansion. While critical of some main features of the Affordable Care Act, Wilensky believes it’s important for the country to get uninsured people covered.